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WELAERMIT APPLICATION FAM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 / <br /> (209) 468-3449 wy�+��' p�—rva - <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - - o '"�"r- <br /> \pgiration is hereby made to San Joaquin County for a permit to construct and/or install the wark described. This application is made in compliance with San <br /> Joaquin County Development Chapter 31115.3 and the Standards of Sn sJoaquin County Environmental Health Department. <br /> HELL Location ZB/i( 9, W6ST bwf. Cross Street Ao t-tE- City 5/d-L-Twj Lp V Pa'l#ors <br /> 'ROPERTY Ownerl lATel K-F1 4H6 Addresszui 4I• >, fS7 C/WL City s,�r��1 T✓� Zip ll�Zoy Phone# <br /> :-57 C,ontractorH,Tcug iL 'Dal L1,Wr Address5-k U S. icier `/1yL, cti�ty 1n `�'"I1p uc#MPf7 Phon nli(c 63( -3 <br /> :onsultant/Sub Contractor Awt ,&mkfJViR9vHmFf/N-Address b 37 it 12-Ab CitysPhoneA(2o i'6 7-/,b6 <br /> HS Coordinates:X ,Y ,Township Range Section <br /> RK TO BE?,EM ED: <br /> EW WELL BORI 1 (54,GEOPROBE,HYD PUNCH,HAND-AUGER,OTHER') n DESTRUCTION(choose type below) <br /> ,,SOIL BORING# Ib AND <br /> u OVER-BORE <br /> [)W ELL# a PRESSURE GROUT <br /> Other. �UL1-d1J S- 61µt Grout Specifications: <br /> ;OMMENTS: <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ��//'' <br /> MONITORING HOLLOW STEM DIA,OF BOREHOLE ' rr MULTIPLE CASINGS?0 YES IytvO WELL CASING DIA: <br /> I EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS &1A TYPE OF CASING; O STEEL 0 PVC I7 OTHER: <br /> VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL-ro—i4L- TREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br /> I AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: $Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: FD112TI-!wD TzA?E .1-I <br /> OTHER: fl OTHER APPROX.BORING DEPTH lo.Sr 1 <br /> a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?_KJO (if YES,list specifications here): <br /> COMMENTS: 6611 eduejU IA ZE ' <br /> �i y.-O a wj.6ES 7-1' t�Jl� iffXit�QSf��i i) i,t)�TF6 '��1i-{ T ' <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> :ounty Winances, Ruleq and Regulations, and alt applicable California State Laws. /1 <br /> ignedx Tide/CompanySEL <br /> ��t7`cY S7/lj�✓ t> �(fo�K Ute�;ll�'tfr(Zh� <br /> rint Name 'YnAV- Date <br /> DEPARTMENT USE ONLY <br /> ;ITE MAP IN UNIT IV FILE, ADDRESS: <br /> VORK PLAN DATED: <br /> pplication Accepted Date Date IssuendZoo <br /> Area <br /> 'rout Inspection By i U Date __ Final Inspection By Date _ <br /> estruction Inspection By Date <br /> OMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> v=erve <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# l7 <br /> :-57_ WC_WAIVER_ C-57 Letter of Autho za ion o sign permit_Encroachment doc_ 1/25/02 <br />